Verification – Need For An Accessible Unit
Date:
Property Fowler Christian Apartments Telephone: 214-821-4061 Name: Address: 105 Juliette Fowler St Fax: 214-818-0345 Address 2: Dallas, TX 75214 TTD/TTY: 711 National Voice Relay Property www.FowlerCommunities.org Email [email protected] Web Site (Please return this form to the above address) TO: Name: Address: City, State, Zip
Dear :
Re: Resident / Applicant Name SSN
HOUSEHOLD MEMBER RELEASE
TO THE Resident/Applicant:
YOU DO NOT HAVE TO SIGN THIS FORM IF THE NAME OR ADDRESS OF EITHER THE PROJECT OR RECIPIENT IS LEFT BLANK.
RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances which would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.
Signature ______Date ______
The owner/agent makes affirmative efforts to ensure that people with disabilities have equal access to HUD’s housing assistance programs. Because there are not enough accessible units to meet the needs of disabled applicants, the owner/agent is required to verify that the resident/applicant named above requires a unit that has been made accessible in accordance with the Uniform Federal Accessibility Standards (UFAS) or the Americans with Disabilities Act Accessibility Guidelines (ADAAG).
The resident has indicated that you are a “medical professional in the know” who can verify the need for an accessible unit or the need for the unit to be modified with specific accessibility features.
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We are required to complete our verification process in a short time period. A self-addressed envelope has been included for your convenience.
If you have any questions, please feel free to contact our office. Thank you, in advance, for your cooperation and prompt response.
______Property Manager Cc: Applicant/Resident File
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THE FOLLOWING TO BE COMPLETED BY INFORMATION PROVIDER
I can cannot verify that the applicant requires an accessible unit or specific unit features, to have equal housing opportunity.
Note: If you can verify the necessity for the accessible unit/accessible features, please answer the questions below. If you cannot verify the necessity for the accommodation, please sign the form and return to the owner/agent.
PLEASE INDICATE ANY AND ALL SITUATIONS THAT APPLY TO THE PERSON WHO SIGNED THIS RELEASE.
1. In my opinion, the applicant/resident’s disability requires that he/she lives in:
A mobility-accessible apartment – This apartment must be fully mobility-accessible in accordance with UFAS/ADAAG. Features include, but are not limited to, roll-under sinks, roll-in showers, wider doorways, lower apartment controls, lower peephole, grab bars etc.
A communication-accessible (hearing/visually accessible) apartment - This apartment must be fully communication-accessible in accordance with UFAS/ADAAG. Features include, but are not limited to, visual alarms, automatic lighting, tactile signage, etc.
An apartment with special accessibility features - If this box is checked, you verify that the resident does not need a fully accessible unit; however, the indicated accessibility features are necessary. Accessibility features include roll-in showers, raised toilets, grab bars, levered door handles, levered faucet controls, solid flooring (tile, laminate, and vinyl), etc.
The following features are necessary for the applicant/resident's unit: ______
______
______
None of the above
2. Is the need permanent or temporary?
Permanent Temporary
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PENALTIES FOR MISUSING THIS VERIFICATION FORM
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
By signing this document, I certify that the information provided is true and correct.
Name and position of verifier:
(Please print)______
Signature of Verifier: ______Date: ______
Address: ______
Telephone: ______email: ______
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